CASE

STUDY
Mild Head Injury
Group C
Week 1
(September 16-18, 2009)

GALANG, Katrina
OBLEFIAS, Marianne
NUCUM, Jordan
PANGILINAN, Ian
Patient’s Profile :
Biographical Data
Name:
SERRANO, Czarmaine Cecilia M.
Sex:
Female
Occupation:
Student
Father:
SERRANO, Lovino
Mother:
SERRANO, Clariza
Address:
19 Cotabato St. Bago Bantay, Q.C.
Patient’s Profile :
Vaccinations and Family Hx
VACCINATIONS:
• PPT
• Measles, Mumps, Rubella (MMR)
• HEPATITIS A
• HEPATITIS B

FAMILY HISTORY
• HYPERTENSION
• DIABETES MELITUS (type unspecified)
Patient’s Profile :
Physical Examination
HEAD
Symmetrical; no visible deformities; visible redness
at right side of forehead.
 
EYES
Normal eyes; symmetrical; pupils reactive to light
 
EARS
No visible abnormalities
 
NOSE
Symmetrical; no visible abnormalities.
 
HAIR
Shiny, healthy hair.
 
Patient’s Profile :
Physical Examination
MOUTH 
Normal without presence of injury
 
SCALP
No pediculosis, dandruff
 
TEETH
1 Missing tooth (extracted last Aug. 30);
1 Erupting tooth
 
SKIN (general)
Normal; No visible lesions or lacerations

LYMPH NODULES
Normal
Patient’s Profile :
Physical Examination
ARMS
Symmetrical

HANDS
Normal

CAPILLARY REFILL
Normal

Others
Knee reflex : Normal
Gait : Normal stance; balanced
 
Patient’s Profile :
Physical Examination
Vital Signs
 
Temperature
36.4°C
 
Heart Rate
93 bpm
 
Respiratory Rate
16 breaths / min
 
Blood Pressure
N/A
Nursing Management:
NCP: Assessment
Subjective Cues:
  “Nautog ako sa kaklase ko” as verbalized
by the client.
 
Objective Cues:
  Palpable, slightly protruding and slightly
inflamed red spot on right forehead; as
evidenced by:
– Redness
– Swelling
– Heat
– Pain
 
Possible disorientation due to dependence on
schoolmate to arrive at clinic
 
Nursing Management:
NCP: Planning – Short Term
Within 1h of nursing
interventions, client will
verbalize that she feels
lesser pain. Skin
demonstrates lesser, if not
the non-existence of
inflammation of the
underlying injury.
Nursing Management:
NCP: Planning – Long Term
Within 2 days of nursing
interventions, client will
verbalize that she no longer
feels any pain. Swelling will
reduce considerably with
minimal bruising.
Nursing Management:
NCP: Interventions
Apply cold compress to
inflamed area.

Rationale: Cold compress

facilitates vasoconstriction thus
reduces swelling and pain and
minimalizes bruising.
Nursing Management:
NCP: Interventions
Observe for signs of
confusion and
disorientation. May be
exhibited by:
– Excessive irritability or
sleepiness.
– Recurrent vomiting
– Increasing headache
– Unsteady balance or
movements
– Disorientation or confusion
Nursing Management:
NCP: Interventions
Rationale:

Force of impact to client’s head

is unknown; Proper observation
may detect possibility of a more
serious injury.
Nursing Management:
NCP: Evaluation of Short
Term Goal
Partially met. Client
verbalized that she “feels
better” after intervention.
However, the inflamed area
still needs continuous care
at home for complete
healing of injury.
Nursing Management:
NCP: Evaluation of Long
Term Goal
Partially met. Limited time
to interact and observe
client gives little opportunity
to monitor and document
condition post-visit.